|
ZINC SULFATE 1 MG/ML INTRAVENOUS SOLUTION [8878]
|
Facility
|
IP
|
$1.68
|
|
|
Service Code
|
NDC 70710-1876-1
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$1.34 |
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.92
|
| Rate for Payer: Multiplan Commercial |
$1.26
|
|
|
ZINC SULFATE 1 MG/ML INTRAVENOUS SOLUTION [8878]
|
Facility
|
IP
|
$2.01
|
|
|
Service Code
|
NDC 66794-255-02
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.11 |
| Max. Negotiated Rate |
$1.61 |
| Rate for Payer: Cash Price |
$1.11
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.61
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.11
|
| Rate for Payer: Multiplan Commercial |
$1.51
|
|
|
ZINC SULFATE 1 MG/ML INTRAVENOUS SOLUTION [8878]
|
Facility
|
OP
|
$2.01
|
|
|
Service Code
|
NDC 66794-255-42
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.11 |
| Max. Negotiated Rate |
$1.61 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.21
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.21
|
| Rate for Payer: Cash Price |
$1.11
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.61
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.11
|
| Rate for Payer: Multiplan Commercial |
$1.51
|
|
|
ZINC SULFATE 1 MG/ML INTRAVENOUS SOLUTION [8878]
|
Facility
|
IP
|
$2.01
|
|
|
Service Code
|
NDC 66794-255-42
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.11 |
| Max. Negotiated Rate |
$1.61 |
| Rate for Payer: Cash Price |
$1.11
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.61
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.11
|
| Rate for Payer: Multiplan Commercial |
$1.51
|
|
|
ZINC SULFATE 1 MG/ML INTRAVENOUS SOLUTION [8878]
|
Facility
|
OP
|
$2.01
|
|
|
Service Code
|
NDC 66794-255-02
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.11 |
| Max. Negotiated Rate |
$1.61 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.21
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.21
|
| Rate for Payer: Cash Price |
$1.11
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.61
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.11
|
| Rate for Payer: Multiplan Commercial |
$1.51
|
|
|
ZINC SULFATE 1 MG/ML INTRAVENOUS SOLUTION [8878]
|
Facility
|
OP
|
$1.68
|
|
|
Service Code
|
NDC 65219-401-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$1.34 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.01
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.01
|
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.92
|
| Rate for Payer: Multiplan Commercial |
$1.26
|
|
|
ZINC SULFATE 1 MG/ML INTRAVENOUS SOLUTION [8878]
|
Facility
|
OP
|
$1.68
|
|
|
Service Code
|
NDC 70710-1876-7
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$1.34 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.01
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.01
|
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.92
|
| Rate for Payer: Multiplan Commercial |
$1.26
|
|
|
ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE [8880]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 8068113500
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.02
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE [8880]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 8068113500
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE [8880]
|
Facility
|
OP
|
$0.23
|
|
|
Service Code
|
NDC 7733398325
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.14
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.14
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
|
|
ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE [8880]
|
Facility
|
IP
|
$0.23
|
|
|
Service Code
|
NDC 7733398325
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
|
|
ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE [8880]
|
Facility
|
IP
|
$0.22
|
|
|
Service Code
|
NDC 2055504000
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
|
|
ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE [8880]
|
Facility
|
OP
|
$0.22
|
|
|
Service Code
|
NDC 2055504000
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.13
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.13
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
|
|
ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE [8880]
|
Facility
|
IP
|
$0.23
|
|
|
Service Code
|
NDC 7733398310
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
|
|
ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE [8880]
|
Facility
|
OP
|
$0.23
|
|
|
Service Code
|
NDC 7733398310
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.14
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.14
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
|
|
ZINC SULFATE 50 MG ZINC (220 MG) TABLET [8881]
|
Facility
|
OP
|
$0.05
|
|
|
Service Code
|
NDC 1000673027
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.03
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.03
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
|
|
ZINC SULFATE 50 MG ZINC (220 MG) TABLET [8881]
|
Facility
|
IP
|
$0.05
|
|
|
Service Code
|
NDC 1000673027
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
|
|
ZIPRASIDONE 20 MG CAPSULE [29778]
|
Facility
|
OP
|
$0.50
|
|
|
Service Code
|
NDC 65862-702-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.30
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.30
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
|
|
ZIPRASIDONE 20 MG CAPSULE [29778]
|
Facility
|
IP
|
$5.79
|
|
|
Service Code
|
NDC 0904-6269-08
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.18 |
| Max. Negotiated Rate |
$4.63 |
| Rate for Payer: Cash Price |
$3.18
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.63
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.18
|
| Rate for Payer: Multiplan Commercial |
$4.34
|
|
|
ZIPRASIDONE 20 MG CAPSULE [29778]
|
Facility
|
OP
|
$0.60
|
|
|
Service Code
|
NDC 55111-256-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.36
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.36
|
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.48
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
|
|
ZIPRASIDONE 20 MG CAPSULE [29778]
|
Facility
|
OP
|
$5.79
|
|
|
Service Code
|
NDC 0904-6269-08
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.18 |
| Max. Negotiated Rate |
$4.63 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.47
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.47
|
| Rate for Payer: Cash Price |
$3.18
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.63
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.18
|
| Rate for Payer: Multiplan Commercial |
$4.34
|
|
|
ZIPRASIDONE 20 MG CAPSULE [29778]
|
Facility
|
IP
|
$0.60
|
|
|
Service Code
|
NDC 55111-256-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.48
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
|
|
ZIPRASIDONE 20 MG CAPSULE [29778]
|
Facility
|
IP
|
$0.50
|
|
|
Service Code
|
NDC 65862-702-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
|
|
ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION [33175]
|
Facility
|
IP
|
$56.40
|
|
|
Service Code
|
HCPCS J3486
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.02 |
| Max. Negotiated Rate |
$45.12 |
| Rate for Payer: Cash Price |
$31.02
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$45.12
|
| Rate for Payer: Health Smart Auto/Commercial |
$33.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$31.02
|
| Rate for Payer: Multiplan Commercial |
$42.30
|
|
|
ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION [33175]
|
Facility
|
OP
|
$56.40
|
|
|
Service Code
|
HCPCS J3486
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.02 |
| Max. Negotiated Rate |
$45.12 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$33.84
|
| Rate for Payer: Aetna of CA Government/Medicare |
$33.84
|
| Rate for Payer: Cash Price |
$31.02
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$45.12
|
| Rate for Payer: Health Smart Auto/Commercial |
$33.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$33.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$31.02
|
| Rate for Payer: Multiplan Commercial |
$42.30
|
|
